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Public Health Services.SOME ANOMALIES IN MEDICAL

CERTIFICATION.INSURANCE practitioners are sometimes in doubt

af their correct course in the certification of an insuredperson who has been treated in hospital and whoremains incapable of work on returning home. Thepractitioner sees the case for the first time when thepatient returns home ; should he give a " first "certificate or an " intermediate " or " continuation "

certificate to follow on the certificates already givenat the hospital ? Obviously, if the insured person isnot to lose two or three days sick benefit-and thereis no reason why he should-the certificate must be an" intermediate " certificate. The case is similar tothat of an insured person who changes his insurancedoctor in the course of an illness. In this case thetransfer may be due to the fact that the first prac-titioner has refused further certificates. We know ofcases in which the second practitioner has given a" first " certificate under these circumstances.Agents of some of the societies insist on a

" final "

certificate being given in cases of pregnancy whenlabour takes place. Here it is obvious that theordinary " final " certificate cannot be used. Thefact of labour taking place and the application formaternity benefit with which a signed statement ofthe date of the confinement must be sent is sufficientevidence of the date on which the sick benefit mustcease. -

Practitioners are frequently notified of their insuredpatients having " ceased to be insured." Where thepractitioner knows that the insured person referredto is actually at work the explanation may be that thenotice refers to a duplicate entry which has beendiscovered and which is being cancelled. But in othercases the approved societies in notifying the insurancecommittees appear to overlook the wide limit whichwas granted to insured persons by the 1920 Act.Under this provision the insured person is entitled tomedical benefit for 12 months after the end of theyear in which he falls into arrears. This provisionwas meant to prevent the insured person from beingdisentitled to medical attendance by reason of a periodof temporary unemployment. So many cards are askedfor by the Insurance Committee for this reason thatthe relationship between the practitioner and hisinsured patient is unnecessarily interfered with to theannoyance of both parties. ’,A number of insurance practitioners would like to

have an answer to the following question : When aninsured person is said to be in arrears to the amountof, say, 5s., why is it necessary to stop an equivalentisum of his sickness benefit every week ?

PORT SANITARY AUTHORITY.The annual report of the Newport (Mon.) Port

Sanitary Authority by the medical officer of health,Dr. J. Howard-Jones, tells of but few cases of infectiousdisease seen during 1924. It is desirable, he states,that suspected ships should be moored and examinedin Barry Iloads, but this procedure has not yet beensanctioned by the Ministry of Health. Little meat orother provision imported was found unfit for humanconsumption. There came to notice 101 cases ofvenereal disease in British subjects and 74 in foreignseamen.

Baits, traps, ferrets, and fumigation accounted for6583 rats, some 70 per cent. of which were females ;97 per cent. of the rats on board ship were black,whereas 99 per cent. of those about the docks werebrown. None were found infected by plague. Lessthan six were found dead per hundred baits distributed,and in seven ships fumigated the average number ofbodies found was 74.

Inspection was made of 2428 ships, of which 407were found defective and had notices issued to them Icalling for the abatement of nuisances. These included I

dirty forcastles, 147 ; foul or defective w.c.’s, 141 ;defective lighting or ventilation, 118 ; accumulationof refuse on deck, 89 ; defective stoves and heatingapparatus, 72 ; food-lockers, none, or defective, ordirty, 32 ; leaking decks, 23 ; living spaces verminous,18 ; defective cable casings or hawse pipes, 18 ; stag-nant water on or under floors of living spaces, 14 ;water impure or storage dirty or defective, 10;insufficient table space or seating, 8 ; w.c.’s used asstorerooms, 6 ; defective bulkheads, 5. Of dirty orverminous beds. 1269 were destroyed. Those generaland particular remarks of the report which concernthe sanitary condition of ships and the diseases ofseamen have already been commented upon in ourcolunms.1 I

INFECTIOUS DISEASE IN ENGLAND AND WALESDURING THE WEEK ENDED JAN. 23RD, 1926.

Notifications.-The following cases of infectious diseasewere notified during the week :-Small-pox, 362 (last week341) ; scarlet fever, 1818 (last week 1717) ; diphtheria,1005 ; enteric fever, 39 ; pneumonia, 1193 (last week1337) ; puerperal fever, 51 ; cerebro-spinal fever, 9 ; acutepoliomyelitis, 3 ; acute polio-encephalitis, 1 ; encephalitislethargica, 31 (last week 67) ; continued fever, 1 ; dysentery,8 ; ophthalmia neonatorum, 113. There were no cases ofcholera, plague, or typhus notified during the week.

Of the 362 cases of small-pox, 26 (last week 60) werereported from the county of Derby, 19 of them from DerbyC.B. ; 175 (last week 143) from the county of Durham,47 of these from Gateshead C.B., 9 from South Shields C.B.,and the remainder from widely scattered urban and ruraldistricts and including 44 from Blaydon, 20 from Chester-le-Street R.D., and 23 from Easington R.D. ; 1 from the countyof Lancaster ; 1 from Lincoln (parts of Lindsey) ; 53 fromthe county of Northumberland (last week 21), including6 from Newcastle-on-Tyne and 20 from Ashington ; 8 fromthe county of Nottingham (last week 16) ; 6 from theEast Riding of Yorkshire (Kingston-upon-Hull); and 92from the West Riding (last week 90), of which 79 (last week77) occurred in Rawmarsh and 2 in Leeds.Deaths.-In the aggregate of great towns, including

London, there was 1 death from enteric fever, none fromsmall-pox, 109 (63) from measles, 5 (3) from scarlet fever,66 (4) from whooping-cough, 50 (16) from diphtheria,57 (19) from diarrhoea and enteritis under 2 years of age,and 87 (11) from influenza. The figures in parentheses arethose for London itself. The recent diminution in thenumber of deaths from influenza is not maintained, thefigures for the last three weeks, working backwards, being87, 81, and 114.

The Services.ROYAL NAVAL MEDICAL SERVICE.

Surg. Lt.-Comdr. L. F. Strugnell to be Surg. Comdr.The following appointments have been made :-Surg.

Comdrs. : D. P. H. Pearson to the Champion; A. G.Malcolm to the Pembroke, addl., for R.N. Barracks, Chatham,and as specialist in ophthalmology ; and T. E. Blunt to theb"1>erzaer, temp. Surg. Lt.-Comdrs : W. I. Gerrard to theR{fmùnt, addl., and to the Egmont for R.N. Hospl., Malta,and as specialist in bacteriology ; K. A. I. Mackenzie to theBritannia, for R.:V’. Sick Quarters, Dartmouth ; J. F.Haynes to the tM’tt/, addl., for Devonport Dockyard;0. J. M. Kerrigan, S. R. Johnston, J. T. Wylie, J. F.Ainley, F. G. Hunt, H. Hurst, J. R. Brennan, and R. W.Nesbitt to the President, addl., for five months’ course ofinstruction.

Surg. Lt. (short service).-P. J. A. The O’Rourke trans-ferred to the permanent list.

ROYAL ARMY MEDICAL CORPS.

Maj. A. L. Otway is restd. to the estabt.Majs. C. T. Edmunds (granted the rank of Lt.-Col.) and

A. S. Williams ret. on retd. pay.Maj. B. G. Patch to be Lt.-Col., vice Lt.-Col. J. H. Robinson

to retd. pay.Capt. S. E. Elphick to be Temp. Capt. and temporarily

relinquishes the rank of Capt.Temp. Capt. A. Wilson relinquishes his commn. and

retains the rank of Capt.

1 THE LANCET, 1925, ii., 1347.

311

TERRITORIAL ARMY.

Capt. A. J. Gibson to be Maj.Lts. T. C. MacKenzie and J. Cohen to be Capts.Lt. D. G. Coutts (late T.A. Res. of Off.) to be Lt.2nd Lt. A. G. Ogilvie (late R. Tank Corps) to be Lt.

ROYAL AIR FORCE.

L. I. Hyder is granted a short service commission as aFlying Officer for three years on the Active List.Flying Officer S. G. Gilmore is promoted to the rank of

Flight Lt.Flying Officer T. Glynn is transferred to the Reserve,

Class D.2.AUXILIARY AIR FORCE.

J. D. Driberg to be Flight Lt., No. 601 (County of London)(Bombing) Squadron. -

INDIAN MEDICAL SERVICE.

The King has approved the retirement of Lt.-Cols. J. H.Hugo and R. McL. Dalziel.

DEATHS IN THE SERVICES.

Inspector-General of Hospitals and Fleets, ThomasBrowne, R.N., whose death occurred at the age of 84 on

Jan. 29th at Weymouth, graduated M.D. R.U.I. with honoursand the gold medal in 1862. In the same year he obtainedthe L.R.C.S. Edin. and joined the Royal Navy as assistantsurgeon in 1863. He was promoted to staff surgeon in 1876,to fleet surgeon in 1883, Deputy Inspector-General in 1893,and Inspector-General in 1899, in which year he retired. Forsome 14 years he served at the R.N. Hospital, Yarmouth,where he was very popular with the patients and theirrelations. From 1894 to 1897 he was in charge of the R.N.Hospital, Bermuda, and from 1897 to 1899 second in chargeof the R.N. Hospital, Plymouth. A keen golfer, he assistedin the formation of the Great Yarmouth Club, of which hewas the first honorary secretary. He married Miss AgnesRobertson Dall, daughter of James Dall, J.P., of NorthBerwick, in 1871, who survives him with a son and fivedaughters.

Lt.-Col. William Wippell Pope, C.M.G., R.A.M.C. retd.,who died on Jan. 31st at Bournemouth, aged 68, receivedhis first commission in 1881 and served with the EgyptianExpedition of the following year, and was at the battle ofTel-el-Kebir (medal with bronze star). In 1888 he took part inthe operations in Zululand and served during the operationson the N.W. Frontier of India in 1897-98. He was also withthe Tirah Expedition Force (medal with clasp), and served inthe South African War, and was present at the defenceof Ladysmith (Queen’s medal with clasp). He reachedthe rank of Lieut.-Colonel in 1901 and retired two yearslater.

Correspondence.

THYROID GLAND AND CALCIUM THERAPY.

..Audi alteram partem."

To the Editor of THE LANCET.

SiR,-In connexion with Dr. Geikie Cobb’s letteron the above subject, and its application to thetreatment of chilblains, may I invite the opinionsnot only of my dermatological colleagues, but alsoof other medical men, as to the value of calcium saltsalone, or of a combination of these with parathyroidgland, in the treatment of patients with a feebleperipheral circulation and chilblains ? Most of mypatients who come to me with chilblains have alreadytaken calcium lactate over a long period withoutstriking benefit; it is true that many of them havetaken it after meals, whereas, as Dr. Arthur Luff

pointed out, it should be given about an hour before,but, even when this error is corrected, the results inmy experience are seldom good. As for parathyroidgland, in spite of all the claims that have been madefor it and of a conscientious personal trial in cases ofchilblain-circulation, varicose and other chronic ulcers,and urticaria, I have never convinced myself that ithad any beneficial effect whatever when given by themouth.

Chilblains are admittedly far commoner in thefemale than in the male sex, and occur chiefly, butnot exclusively, in girls and women belonging to acertain type, which deserves a monograph to itself.This type is well known to dermatologists and is seencommonly in girlhood, although it can be recognisedat a later age, when, however, its manifestations are,as a rule, less obvious. Its subjects are usually fatand oedematous-looking and their legs are, perhaps,their most characteristic feature. These are coarseand unshapely and blue from vascular stasis, mostmarked in the lowest third, which is often icy cold tothe touch; there is hyperkeratosis at the pilo-sebaceous orifices-keratosis pilaris-around each ofwhich is seen a bluish halo of stasis ; the lanugo hairsare often long and coarse, and the skin as a whole isharsh, feels thickened, and cannot be pinched up fromthe underlying subcutaneous tissue. The same

vascular stasis and the keratosis pilaris are also seenon the extensor surfaces of the upper arm. Dr. H.MacCormac and Dr. Parkes Weber recently drewattention to these patients in describing " a peculiarerythema of the legs," and it has been suggested thatthe wearing of thin or openwork stockings is an

aggravating cause of the vascular stasis. Where thisis most evident-viz., on the postero-external surfaceof the lowest third-actual chilblains often occur, andalso, if the patient be tubercular, the nodules of Bazin’serythema induratum ; in fact, it is doubtful if thelatter is ever seen except in patients of this type.I agree, however, with Dr. Guy that in them nodulessimilar to those of erythema induratum may occurfrom embolism of bacteria other than the tuberclebacillus--e.g., B. coli and streptococci.The aetiological factors responsible for the produc-

tion of this type afford plenty of scope for speculation.That there is a disturbance of the endocrine-sympa-thetic system would appear likely. Thus, as has beensaid, females are far more often affected than males,and my experience is that in most patients thereare menstrual irregularities ; menstruation is usuallylate in beginning, often irregular and scanty, and notuncommonly several periods are missed altogether.Heredity is undoubtedly a factor of importance ;frequently the history is volunteered that the motherwas similarly affected when a girl, and I have beenseveral times consulted by two or three sisters forthe same condition. I have thought that psoriasisis commoner in girls of this type than can be explainedby mere coincidence ; when it does occur, the psoriasispatches predominate on the legs below the knee andto a less extent on the extensor surface of the upperarm, the body often being completely free, and it iscommon in these situations for the eruption to befollicular, the mouths of the pilo-sebaceous follicles,already the site of keratosis pilaris, being encircledby a little halo of psoriasis. As regards the calciummetabolism of these patients Dr. W. W. Payne kindlymade investigations of the blood-calcium for me ina few cases, but the results were inconstant; no

striking diminution either of the total or ionised calciumwas found in any case, and in some the figures wereabove normal.

I have found the oral administration of iodine inlarge doses, either alone or in combination with thyroidgland, far more efficacious than anything else in thesepatients, not only as regards the acroasphyxia andchilblains, but also as regards their general health andsense of physical fitness. I am, of course, aware thatSir Arbuthnot Lane would attribute the clinical

picture I have briefly sketched entirely to intestinalauto-intoxication ; it is true that in the few casesthat have been completely investigated very markeddelay in the colon was found, and very possibly auto-toxaemia may be an important factor, but it cannot, PI think, be the only one.

I am, Sir, yours faithfully,Devonshire-place, W., Feb. lst, 1926. H. W. BARBER.H. W. BARBER.